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Attach to complete plans for the system and submit to the County only on paper not less thanU <br />OCT0 2 2018 inches in size <br />SBD -6398 (80313) <br />BURNETT COUNTY <br />ZONING <br />County <br />Safety and Buildings Division <br />1400 E Washington Ave <br />Sanitary Permit Number to he filled in by Co.) <br />p <br />P.O. Box 7162 <br />S A <br />V\ �� W: <br />Madison, WI 53707-7162 <br />0 396 cs7-1 -137 <br />Sanitary Permit Application <br />State Transaction Number <br />A/ <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />ores in accordance with the Privacy Law, s. 15.04 1 m , Stats. <br />/ O� <br />/ <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # tD - <br />odd 1'1 fo /h <br />.5-/'n- <br />Property Owner's Mailing' ddress <br />Property Location <br />,1(7--'-2 7 <br />Govt. Lot <br />y, %., Section <br />City, State <br />Zip Code <br />Phone Number <br />i J <br />Cqd <br />-'3 <br />— <br />(circle ones <br />,4 IIVA <br />T _410 N; R --_/_- E o <br />II. Type Building <br />Lot # <br />of (check all that apply) <br />❑ 1 or 2 Family Dwelling -Number of Bedrooms <br />SubdivisionName <br />� I / <br />&,,,,,J Ad,], �d V' ��i <br />Block# <br />❑ Public/Commercial -Describe Use r <br />. <br />❑ City of <br />❑ State Owned - Describe Use -^ <br />❑ Village of <br />CSM Number <br />PIrown of C- 0 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />y <br />Replacement System <br />� p y <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑Permit Renewal <br />El Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />j00 <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (so <br />System Elevation <br />A15U <br />17 <br />6 r� <br />� o <br />yam; ;2- <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units <br />y o b <br />New Tanks Existing Tanks <br />C <br />0 <br />p <br />a, U fn m rn <br />w C7 <br />0. <br />Septic or IioidieebTan'1i? <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />WADE RUFSHOLM <br />227691 <br />715-349-7286 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO BOX 514, SIREN, WI 54872 <br />VWHII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />D o <br />'37,S <br />Date Issuu/ed <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />3 7^' <br />�f <br />IX. Conditions of Approval/Reasons for Disapproval <br />wth <br />A'PROVED <br />ir nD E/I <br />uMVE <br />Attach to complete plans for the system and submit to the County only on paper not less thanU <br />OCT0 2 2018 inches in size <br />SBD -6398 (80313) <br />BURNETT COUNTY <br />ZONING <br />